<%@ include file="/common/taglibs.jsp"%>

<head>
    <title><fmt:message key="wellness.title"/></title>
    <meta name="heading" content="<fmt:message key='wellness.heading'/>"/>
</head>

<body id="signup"/>

<div class="separator"></div>

<s:form name="wellnessProfileForm" action="saveMainWellness" method="post" validate="true">
    <li class="info">
        <fmt:message key="wellness.message"/>
    </li>

    <s:textfield key="main.companyname" name="main.companyname" required="true" cssClass="text large"/>
	
	<s:textfield key="main.physicianname" name="main.physicianname" required="true" cssClass="text large"/>

	<s:textfield key="main.healthplanname" name="main.healthplanname" required="true" cssClass="text large"/>
	<li>
        <div>
            <div class="left">
                <s:textfield key="main.clientid" name="main.clientid" theme="xhtml" required="true" cssClass="text medium"/>
            </div>
            <div>
                <s:textfield key="main.groupnumber" name="main.groupnumber" theme="xhtml" cssClass="text medium"/>
            </div>
        </div>
    </li>

    <s:textfield key="main.birthdate" name="main.birthdate" theme="xhtml" cssClass="text medium"/>

	<li>
        <div>
            <div class="left">
                <s:textfield key="main.race" name="main.race" theme="xhtml" required="true" cssClass="text medium"/>
            </div>
            <div>
                <s:textfield key="main.gender" name="main.gender" theme="xhtml" cssClass="text medium"/>
            </div>
        </div>
    </li>

    <div class="separator"></div>

    <li class="buttonBar bottom">
        <s:submit key="button.save" cssClass="button"/>
        <s:submit key="button.cancel" name="cancel" cssClass="button"/>
    </li>
</s:form>

<script type="text/javascript">
    Form.focusFirstElement(document.forms["wellnessMainForm"]);
</script>